Practical Applications

A Dental Esthetic Checklist forTreatment Planning in Esthetic DentistryJoseph R. Greenberg, DMD;̂ and Meredith C. Bogert,

Abstract: A dental esthetic checklist form has been introduced

for use in the diagnostic work-up of a patient accepted for

treatment in an Advanced Education in General Dentistry

program. The checklist, divided into seven basic criteria, is

not a complete list of all possible categories and nuances

that an esthetic restorative assessment might include. The

correct initial identification of these criteria does not limit the

dentist from pursuing more detail; in fact, this checklist is an

introductory organizer that invites further exploration, in the

authors' experience, the use of this form prompts the student

to broaden his or her vision from purely a dental/periodon-

tal focus to one that encompasses lip, cheek, and tongue

configurations; smile; facial features; and related planes of

symmetry. This approach directs the dental treatment plan

toward the important additional goal of dentofacial harmony.

One objective of the Advanced Education in General

Dentistry Program at the Kornberg School of

Dentistry is to elevate the conceptual and technical

treatment standards of its students. Fundamental to the resi-

dents' patient treatment experience is thorough examination,

diagnosis, and treatment planning. Recent publications assert

that the face is the first view requiring assessment by a dental

practitioner,' thus this is the initial assessment made by the

residents in performing a work-up in a patient for treatment.

A dental esthetic checklist form, divided into seven basic

criteria, bas been introduced for use in tbe diagnostic work-

up of a patient accepted for treatment in the program. This

checklist is not a complete list of all the possible categories

and nuances tbat a dental estbetic restorative assessment

might include; another popular esthetic checklist includes 13

factors.' However, sources in the dental literature consistent-

ly describe tbese seven basic criteria as essential to successful

treatment results. The correct initial identification of these

items does not limit the practitioner from pursuing more

detail; instead, this checklist is an introductory organizer

that invites further exploration. In the authors' experience,

use of this form has prompted students to broaden their

visions from purely a dental/periodontal focus to ones that

emcompass lip, cheek, and tongue configurations; smile; fa-

cial features; and related planes of symmetry. This approach

directs the dental treatment plan toward the additional goal

of dentofacial harmony.

The "Dental Esthetic Checklist for Treatment Planning" is

displayed in Table 1. A previous article' defined and explained

tbe facial and dental terminology used in the first three fac-

tors, but a discussion of supporting data is pertinent here.

CHECK POINT 1: DM = FMThe value of aligning the maxillary dental midline (DM) to

the patient's facial midline (FM) is cited with frequency in the

removable prosthodontics literature.'"''The first text on dental

esthetics^ stated that "the midline should be perpendicular

to tbe incisai and occlusal plane and parallel to tbe midline

of the face." Chiche and Pinault' wrote, "Harmonious facial

features are more symmetrical close to the facial midline and

more asymmetrical away from it." Spear'' reported that, in

smile design, the starting point of the esthetic treatment plan

is the facial midline. Morley and Eubank'" state that a practical

approach to locating the FM requires two reference points:

'Clinical Professor of Restorative Dentistry and Course Director, Advanced Restorative Dentistry, The Kornberg School of Dentistry

at Temple University, Philadelphia, Pennsylvania; Clinical Professor of Periodontics, The University of Pennsylvania School of

Dental Medicine, Philadelphia, Pennsylvania

^Associate Professor, Interim Chair of Restorative Dentistry, Director of the AEGD Program in the Department of Restorative

Dentistry, The Kornberg School of Dentistry at Temple University, Philadelphia, Pennsylvania

630 Compendium October 2010—Volume 31, Number 8

Greenbera and Boaert

Table 1: Dental Esthetic Checklist for Treatment Planning

Purpose:

Terminology:*

1. DM = FM?

2. DV = FV?

3. DH = FH?

To emphasize certain key factors in the comprehensive dentofacial examination, leading to diagnosis andtreatment planning. Note: Facial symmetry should be a key driver of the dental esthetic treatment plan.

FM = Facial MidlineDM = Dental Midline

FV = Facial Vertical AxisDV = Dental Vertical Axis

FH = Facial HorizontalDH = Dental Horizontal

D Y D N (Measure and record/sketch discrepancy).

D Y D N (Measure and record/sketch discrepancy).

n Y D N (Measure and record/sketch discrepancy).

• N4. Are both maxillary central incisors equal ¡n position, symmetry, color/shade; and are they located at: FM/FV/FH? D YDo the tooth proportions and composition follow the rules of biometrics?' D Y D N

5. Does the incisai edge line of the maxillary anterior teeth follow the superior contour edge of the lower lip?If not, please describe or sketch.

6. Does the incisai edge line form an "attractive" (convex, "gull-wing," or straight) edge pattern?Describe the relationship of lip aperture to the dental composition in "wide smile," have patient bite tightly and say "E." (Check one.)D High lip line smile (> 4 mm of gingival display apical to cervical gingival margins).U Normal lip line smile (0 to 3 mm to 4 mm of gingival display).D Low lip line smile (lip covers all gingiva and/or maxillary anterior).

7. Profile and Phonetic/Speech Evaluation:a. Examine relationship of anterior teeth to the patient's facial outline from a profile perspective. Record your observations.b. Have the patient repeat the "F" and then "V" sounds to test proper positioning of the maxillary incisai edges. Note your findings.c. Have the patient say the "S" sound (can use words such as "Mississippi") while seated upright to evaluate occlusal vertical

dimension and freeway space. Note your findings.

•Greenberg and Ho' 'Chu "̂

Figure 1 and Figure 2 This patient's smile view showed complete fixed upper porcelain-fused-to-rnetal (PFM) dental restorations

with DM approximately centered to Cupid's Bow. The full-face smile view revealed a significant discrepancy between DM and FM.

In this case, Cupid's Bow was not a reliable reference to FM. This aspect of the treatment result was approved in advance by the

patient during the provisional restoration phase.

the nasion (a point between the eyebrows) and the base of the

philtrtim (also referred to as Cupid's Bow). A line connecting

these two landmarks should locate the FM and also determine

the direction of the midline; this factor is referred to as facial

vertical axis (FV) on this dental esthetic checklist.

The maxillary DM is the important visual dental land-

mark. It coincides with the labial frenum and the FM in 70%

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of the population." The mandibular DM is either in motion

during function or covered by the maxillary teeth at rest or in

smile. In 75% of the population, it does not coincide with the

maxillairy midline,'^ thus the mandibular dental midline is not

usually visually important in esthetic dentistry."

The importance of aligning DM and FM in dental esthetic

endeav )rs has been questioned by Kokich et al. ''' Their findings

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Practical Applications

Figure 3 This patient had dental crowns on her maxillary

central and lateral incisors that were located at DM = FM

but displayed a vertical axis discrepancy such that DV was

not congruent with FV. Root caries was found around the

margins of these crowns, necessitating their replacement.

Figure 5 This patient's dental restorations revealed a

marked discrepancy between DH and FH.

Figure 7 New complete upper and lower fixed composite-

fused-to-gold dental restorations for this patient with DH in

harmony with FH.

Figure 4 New zirconia-based, all-ceramic, full-coverage

crowns on the patient in Figure 3 with corrected

vertical axes.

Figure 6 Smile view of the patient in Figure 5.

IFigure 8 Smile view of the completed restorations.

su^ested that neither dentists nor laypersons notice a difference

in DM to FM deviations of up to 4 mm. T his study of altered

photographic images of natural smiles used only one reference

point—Cupids Bow—and displayed no facial structures be-

yond the upper and lower lips. The patient used for this section

of the article did not seem to have a sharply defined Cupid s

Bow. This does not seem to satisfy the requirements for a facial

reference point as previotisly described. By contrast, a more

recent Web-based study'''witb a larger sample size (2185 valid

responses) used altered images of natural dentitions with full

faces side by side. This study found strong preferences gainst

midline shifts at 3 mm. Without a full-face reference, one may

not be truly be assessing the impact of dental composition varia-

tions from the patients point of view (Figure 1 and Figure 2).

1632 Compendium October 2010—Volume 31, Number 8

Flores-Mir et al"" suggested that laypersons naturally

see dental esthetics as part of overall facial esthetics unless

intentionally directed to a close-up view of the dentition.

Pattoff and Ozar'^ wrote that although the expertise of the

professional alone is considered sufficient to determine

if an oral health need has been met, in esthetic dentistry

it is the patient's judgment alone that is sufficient to de-

termine if a result is appropriate. If the dental profession

accepts these two articles as evidence based, it may wish

to consider inclusion of the dentofacial examination as a

component of diagnosis and treatment planning in the

dental school curriculum. Similarly, if patients naturally

see the full face and view their teeth and smile esthetics as

part of this whole, then full-face images should become

standard in professional presentations and publications on

esthetic dentistry.

CHECK POINT 2: DV = FVDM should coincide with FM whenever possible. When

DM = FM cannot be achieved, it is still highly desirable

for the dental vertical axis (DV) to parallel the facial ver-

tical axis (FV).'2 " This is referred to as DV = FV. It is

possible but undesirable to have a correctly located DM

with an incorrect DV. Any canted DV in either a restored

or natural dentition is considered unattractive'" (Figure 3

and Figure 4).

CHECK POINT 3: DH = FHThe interpupillary line, ophraic line (eyebrows), and com-

missural line impart an overall sense of harmony and hori-

zontal perspective to the esthetically pleasing face." None

of these three anatomic landmarks absolutely defines the

facial horizontal 100% of the time, but it is recommended

to use them as general reference planes and then finalize

the facial horizontal (FH) determination as perpendicular

to the already determined FV. The incisai edge line (incisai

plane) of the maxillary anterior dental composition and

the buccal cusp tips of any posterior teeth on display in

wide smile should be symmetrical to the FH plane (Figure

5 through Figure 8).

There is considerable agreement for the esthetic impor-

tance of dental horizontal (DH = FH) among patients and

dentists, '̂'̂ '*'"*" '̂"'̂ " yet it is often difficult to record the

visually apparent FH using functionally oriented dental

articulators."" Supplementary devices now are available to

dentists to transfer FH position to the dental laboratory

technician accurately.'

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Greenberg and Bogert

CHEC!KPOINT4:

Are höfdi maxillary central incisors equal in position,symmetry, color/shade; and are they located atFM/FV/FH? Do the relative tooth proportionsand specifications follow the rules of biometrics?Although naturally occurring maxillary central incisors do

not alwîays measure the same in width and length, it is still

recommended to strive for a matched pair of central incisors

at FM = DM, FV = DV, and FH = DH when fabricating

maxillaiy anterior dental restorations.' These pairs anchor

the cerjtral symmetry of the face to the dental composi-

tion, Which is a universally recognized feature of physical

attractiveness.'^''^ Kokich et al concluded that asymmetric

alterations make teeth more unattractive not only to dental

professionals but also to laypersons.^'

Figure 9 This patient sought treatment for color correction

of her maxillary lateral incisors. The right lateral incisor was

a porcelain veneer and the left one was the pontic of an

all-ceramic, resin-bonded bridge, which had debonded on

numerous occasions and would be replaced with an etched

PFM resin-bonded prosthesis."

Figure 10 Closer evaluation using the dental esthetic check-

list also revealed unequal gingival margins and unattractive

overall composition. The patient desired treatment of

those Conditions.

Compendium 633

Practical Applications

Figure 11 The Proportion Gauge was used to analyze toothproportion, revealing the need for crown lengthening ofthe right central incisor to achieve a naturally attractiveproportion of 78% width to length. It was decided thattreatment would be accomplished by apical repositioningof the gingival margin.

Figure 13 The same patient after apical repositioning of thegingival margins for the right lateral and central incisorsand incisai lengthening ofthe left central incisor.

Figure 12 The Proportion Gauge showed a need to lengthenthe crown of the left central incisor also. Lengthening thiscrown in an incisai direction fulfilled the 78% width-to-length proportion and satisfied Check Points 3, 4, 5, and6, as well. The method chosen to lengthen this tooth wasdirect composite resin bonding. There were other possibletreatment modalities but only one correct treatment plan.

Figure 14 A 6-month postoperative view of the gingivalsurgery. It also shows the appearance of the right lateralincisor porcelain veneer and the left lateral incisor pontic ofthe etched PFM resin-bonded retainer. Note that the apicalthird of the pontic was fabricated to harmonize with thelength of the right lateral incisor.

Figure IS The completed smile for this patient. Figure 16 A full-face smile view of the patient.

1634 Compendium October 2010—Volume 31, Number 8

Practical Applications

Figure 17 This patient displayed lower lip asymmetry. Therecommendation of Check Point 5 is to follow the FH insuch a situation, as presented here. A dental compositionthat follows a symmetrical lower lip contour can be seenagain in Figure 15.

Figure 18 The incisai edge line of this patient indicates anunattractive, concave pattern. There are also discrepancies ofDM to FM, DV to FV, and DH to FH. Although the maxillarycentral incisors seem equal in size to each other, they werenot centered in the patient's face.

Figure 19 The final tooth and dental implant-supported

maxillary fixed prosthesis achieved a more convex incisai

edge line. Corrections of DM to FM, DV to FV, and DH to

FH also were achieved and the maxillary central incisors

were centered in the face as a result. The patient's lower lip

was asymmetrical to FH so, as in Figure 17, the restoration

abided by Check Point 5.

The Proportion Gauge (Hu-Friedy, www.hu-friedy.com)

can be used to establish the 78% width/length proportion

of maxillary central incisors as described by Chu.̂ "* This

gauge reliably produces visually attractive teetb based on data

compiled from natural anatomic measurements. Biometrics'^''

is a recommended methodology to achieve pleasing upper

and lower anterior tooth compositions true to natural dental

anatomic specifications (Figure 9 through Figure 16).

CHECKPOINTS:Does the incisai edge line of the maxillaryanterior teeth follow the superior contouredge of the lower lip?There is general agreement that the incisai edge line of the

maxillary anterior teeth (an imaginary line scribing through

the incisai edges) should have an equidistant consistency to

the superior contour edge of the lower lip." In cases in which

the lower lip exhibits asymmetry, the recommendation is to

follow the facial horizontal axis as previously determined and

disregard the lower lip (Figure 17).

CHECK POINT 6:Does the incisai edge line form an "attractive"(convex, "gull-wing," or straight) edge pattern?Attractive incisai edge lines can be convex, "gull-wing," straight,

or some combination of these—but never concave in a down-

ward direction" (Figure 18 and Figure 19). While examining

the incisai edge line and its relationship to the lips, it is a good

time to note the relationship of the lip aperture to the dental

display in "wide smile" and repose. The patient usually will give

his or her widest smile when asked to bite tighdy and say "E."

CHECK POINT 7:Profile and Phonetic/Speech EvaluationSpontaneous clear speech is extremely important to the patient.

Tbe "F" and "V" sounds can be used to determine correct

maxillary incisai edge position. The "S" sound has been de-

scribed to test for adequate freeway space when an alteration

in occlusal vertical dimension is being considered."*'*

Current writings question the emphasis that orthodontists

traditionally have placed on profile view and lateral cephalomet-

ric analyses, but it is still important for tbe dentist to examine,

relate, and document the profile view of the teeth, lips, and vis-

ible periodontium to the facial complex.^'' Ackerman wrote that

the future of dentofacial esthetic treatment planning lies in the

clinician's ability to envision the patient's desired 3-dimensional

soft-tissue outcome and then engineer the dental and skeletal

I 636 Compendium October 2010—Volume 31, Number 8

Practical Applications

hard tissues to produce this desired result. This science quickly is

evolving with the aid of new technology that produces 3-dimen-

sional images. As dentists learn to acquire, interpret, and share

these images with their patients, new standards for dentofacial

esthetic examination, diagnosis, and treatment planning may

be established by the dental profession.

CONCLUSIONThe dental literature now states that ideally, a dentist's work

should conform to the dental profession's standards for teeth

that are properly shaped and colored within an individual

patient's complete dentition and balanced with the patient's

gingival and facial features.^

A seven-point dental esthetic checklist that was developed

for dentofacial examination, diagnosis, and treatment plan-

ning in an Advanced Education in General Dentistry program

was presented. Its purpose is to guide the clinician, via the

identification of an organized sequence of physical parameters

recognizing major elements of dental composition and funaion

and placing these elements in a symmetrical relationship within

the facial complex, to a desired end point. This result should

be a harmonious integration of displayed dental components

with facial structures that patients and dentists will recognize as

pleasing and attractive and that will flilfill the professional obli-

gations of the dentist to these newly published ethical standards.

ACKNOWLEDGMENTSDental laboratory technology by J. Lee (Figures 2, 4, 14, and

19), R. Rafetto (Figure 8), and A. Canterbury (Figure 17).

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I 638 Compendium October 2010—Volume 31, Number 8

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